Disabilities and the Medical Student

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As the proportion of students deemed to have disabilities has grown, so has the pressure on colleges to ensure that they are meeting the students’ educational needs and treating them fairly from admissions to graduation.

Medical schools face a particular challenge on that score, panelists argued Monday at the annual meeting of the Association of American Medical Colleges in Washington, because they hold students to a set of technical requirements as well as academic ones -- and students’ abilities to meet those standards may not become clear until well into their medical school careers.

The session, “Medical Students With Disabilities: Individual vs. Institutional Rights and Responsibilities,” focused on the requirements (legal and moral) on medical schools to ensure equitable participation in their programs for students with physiological, mental or learning disabilities.

The legal requirements, as laid out in two major federal laws -- Section 504 of the Rehabilitation Act of 1973 and the Americans With Disabilities Act -- and a patchwork of state and local laws, generally define a disability as an impairment that “substantially limits” a major “life activity” (such as walking, seeing, hearing or learning). Courts have interpreted the laws to require educational institutions to provide a student with “reasonable” modifications to participate in their programs, generally defining as “unreasonable” changes or accommodations that fundamentally alter the nature of the academic program.

Medical schools have “gotten good at selecting the most academically qualified” students in the admissions process, said Daniel J. Wilkerson, deputy university counsel at the University of Colorado Health Sciences Center at Denver, and editor of “Medical Students with Disabilities: A Generation of Practice,” a monograph released this fall by the medical school association.

Where they’ve tended to have more trouble, Wilkerson said, is in defining the technical skills that students must attain to be promoted through their programs and to get their medical degrees and be qualified for clinical practice, Wilkerson said. “Sometimes you don’t know whether a student is qualified [for your program] upon admission – sometimes you can’t tell until the point of promotion or graduation,” he said.

Kalindi Trietley, director of learning and disability services at Dartmouth Medical School, agreed that “it all hinges on technical standards” (which, not coincidentally, was the title of her talk). Dartmouth judges the performance of its medical students in two ways, she said: on a set of academic standards showing that they’ve mastered knowledge and a set of skills (a judgment made primarily through the awarding of grades), and a set of technical requirements (which it calls “standards for capacity”) suggesting what students must be able to do to successfully complete the program.

To treat students with disabilities equitably, Trietley said, medical schools should use their technical requirements to define what students must do, not how they should do them. For instance, it is perfectly reasonable for a medical school to require students to have the “perceptual capacity” to hear heart sounds, but not for it to require all students to be able to actually “hear” the sounds.

Having clear policies alone isn’t enough, Trietley said -- colleges must communicate them clearly so that students know, before they enroll and throughout their careeers, what is required of them. Dartmouth also requires students to sign a statement saying that they saw and understood the requirements, she said.

Wilkerson of the University of Colorado said that he was unaware of cases in which a student had successfully challenged a medical school's technical standards. And while it is certainly wise for institutions to try to ensure that institutions clearly define those standards so that prospective students know what will be expected of them down the road, he said, neither institutions nor students themselves can assess with certainty how successfully a student -- with or without disabilities -- will be able to maneuver through the requirements.

Which is why, Trietley said, colleges should be guided, in deciding how and when to accommodate students’ needs, not just by what they perceive to be “reasonable” from a legal standpoint, but “what’s generous, creative, and educationally sound,” too.